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Contrast Volume During Primary Percutaneous Coronary Intervention and Subsequent Contrast-Induced Nephropathy and Mortality

Giancarlo Marenzi, MD; Emilio Assanelli, MD; Jeness Campodonico, MD; Gianfranco Lauri, MD; Ivana Marana, MD; Monica De Metrio, MD; Marco Moltrasio, MD; Marco Grazi, MD; Mara Rubino, MD; Fabrizio Veglia, PhD; Franco Fabbiocchi, MD; and Antonio L. Bartorelli, MD
[+] Article and Author Information

From the University of Milan, Milan, Italy.


Grant Support: By the Centro Cardiologico Monzino, Institute of Cardiology, University of Milan, Milan, Italy.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Marenzi (giancarlo.marenzi@ccfm.it).

Requests for Single Reprints: Giancarlo Marenzi, MD, Centro Cardiologico Monzino, via Parea 4, 20138 Milan, Italy; e-mail, giancarlo.marenzi@ccfm.it.

Current Author Addresses: Drs. Marenzi, Assanelli, Campodonico, Lauri, Marana, De Metrio, Moltrasio, Grazi, Rubino, Veglia, Fabbiocchi, and Bartorelli: Centro Cardiologico Monzino, via Parea 4, 20138 Milan, Italy.

Author Contributions: Conception and design: G. Marenzi, E. Assanelli, G. Lauri, I. Marana, F. Fabbiocchi, A. Bartorelli.

Analysis and interpretation of the data: G. Marenzi, E. Assanelli, J. Campodonico, G. Lauri, I. Marana, M. De Metrio, M. Moltrasio, M. Grazi, M. Rubino, F. Veglia, F. Fabbiocchi, A. Bartorelli.

Drafting of the article: G. Marenzi, I. Marana, F. Veglia, A. Bartorelli.

Critical revision of the article for important intellectual content: E. Assanelli, J. Campodonico, G. Lauri, I. Marana, M. De Metrio, M. Moltrasio, M. Grazi, M. Rubino, F. Veglia, F. Fabbiocchi, A. Bartorelli.

Final approval of the article: G. Marenzi, J. Campodonico, I. Marana, M. De Metrio, M. Moltrasio, M. Grazi, M. Rubino, F. Veglia, F. Fabbiocchi, A. Bartorelli.

Provision of study materials or patients: M. De Metrio, M. Moltrasio, F. Fabbiocchi.

Statistical expertise: F. Veglia.

Obtaining of funding: G. Marenzi, A. Bartorelli.

Administrative, technical, or logistic support: G. Marenzi, J. Campodonico, G. Lauri, M. Rubino, A. Bartorelli.

Collection and assembly of data: G. Marenzi, E. Assanelli, G. Lauri, M. De Metrio, M. Moltrasio, M. Grazi, M. Rubino.


Ann Intern Med. 2009;150(3):170-177. doi:10.7326/0003-4819-150-3-200902030-00006
Text Size: A A A

Background: Contrast-induced nephropathy (CIN) frequently occurs in patients with acute ST-segment elevation myocardial infarction (STEMI) who are undergoing primary percutaneous coronary intervention, and CIN is associated with a more complicated clinical course and increased mortality.

Objective: To investigate the association between absolute and weight- and creatinine-adjusted contrast volume, CIN incidence, and clinical outcome in the era of mechanical reperfusion of STEMI.

Design: Prospective, observational study.

Setting: A university cardiology center in Milan, Italy.

Patients: 561 consecutive patients with STEMI who were undergoing primary percutaneous coronary intervention.

Measurements: For each patient, the maximum contrast dose was calculated, according to the formula (5 × body weight [kg])/serum creatinine, and the contrast ratio, defined as the ratio between the contrast volume administered and the maximum dose calculated, was assessed. An increase in serum creatinine of more than 25% from baseline was defined as CIN.

Results: 115 (20.5%) patients developed CIN. In-hospital mortality was higher among patients with CIN than those without CIN (21.4% vs. 0.9%; P < 0.001). The maximum contrast dose was exceeded in 130 (23%) patients. Patients who received more than the maximum contrast dose (contrast ratio >1) had a more complicated in-hospital clinical course and higher mortality rate (13% vs. 2.8%; P < 0.001) than did patients with a contrast ratio less than 1. Development of CIN was associated with both contrast volume and contrast ratio.

Limitation: The association between contrast volume and outcomes was observed in a single center and could be due to comorbid conditions, disease severity, or an unknown factor.

Conclusion: During primary percutaneous coronary intervention for STEMI, higher contrast volume is associated with higher rates of CIN and mortality; however, further study is needed to determine whether limiting contrast volume would improve patient outcome.

Funding: Centro Cardiologico Monzino, Institute of Cardiology, University of Milan.

Figures

Grahic Jump Location
Figure.
Predicted probability of CIN.

CIN = contrast-induced nephropathy. Top. Predicted probability by quartile of contrast volume, as estimated by logistic equation (model 2). Left ventricular ejection fraction was set to 48.8% (population average) and serum creatinine concentration to 97.2 µmol/L (1.1 mg/dL) (population average). Bottom. Predicted probability by quartile of contrast ratio, as estimated by logistic equation (model 2). Left ventricular ejection fraction was set to 48.8% (population average) and time to reperfusion to 3.4 hours (population average).

Grahic Jump Location

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Comments

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Contrast-Induced Nephropathy is a Misleading Expression for Renal Impairment after PCI
Posted on February 15, 2009
Hitinder S. Gurm
University of Michigan Medical Center and Veterans Affair Ann Arbor Healthcare System, Ann Arbor, MI
Conflict of Interest: None Declared

We would like to commend Marenzi et al.(1) on their excellent study demonstrating an association between contrast volume and renal failure in patients undergoing STEMI. As the authors have astutely pointed out, it is not clear if the association is causal or is simply related to confounding. In general, patients who are the sickest or have a suboptimal result after PCI are more likely to receive a greater contrast volume.

While studies of bicarbonate, acetylcysteine, or different contrast agents have shown a dramatic reduction in contrast-induced nephropathy (CIN), a corresponding reduction in mortality has not been demonstrated (2,3). While one cannot disagree with the need to avoid excess contrast volume in any patient undergoing PCI, it is unlikely that contrast media is the sole factor responsible for renal dysfunction in the patient population undergoing primary PCI.

We believe the term CIN to describe this syndrome is misleading and prematurely ascribes a causal relationship. It would be preferable to use a more neutral expression such as Nephropathy Associated with Primary PCI (NAPP) to describe this entity until the etiopathogenesis of this syndrome is better delineated.

References

1. Marenzi G, Assanelli E, Campodonico J, et al. Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality. Ann Intern Med. Feb 3 2009;150(3):170- 177.

2. Nallamothu B, Shojania K, Saint S, et al. Is Acetylcysteine Effective in Preventing Contrast-Related Nephropathy? A Meta-analysis. Am J Med. 2004;117:938-947.

3. Hogan SE, L'Allier P, Chetcuti S, et al. Current role of sodium bicarbonate-based preprocedural hydration for the prevention of contrast-induced acute kidney injury: a meta-analysis. Am Heart J. Sep 2008;156(3):414-421.

Conflict of Interest:

None declared

Contrast Volume During Primary Percutaneous Coronary Intervention...
Posted on June 23, 2009
Anonymous Anonymous
No Affiliation
Conflict of Interest: None Declared

I read with interest the article by Marenzi et al, Ann Intern Med. 2009;150:170-177, "Contrast Volume During Primary Percutaneous Coronary Intervention and Subsequent Contrast-Induced Nephropathy and Mortality".

I am puzzled by the conclusion that there is a volume limit for safe use of contrast during STEMI PCI. As best I can determine from the article, the risk of contrast volume is continuous and nearly linear.

The "limit" suggested by the authors (=(Wt in Kg x 5)/creatinine in mg/dl) seems specious (1). There was no demonstration of a clean break-point in risk. The apparent break point shown in Figure 4 is illusory, reflecting a non-proportional scaling of the X axis. Less contrast is safer, and this is true at every level of dye exposure. More contrast is more dangerous, and this is true at level of dye exposure.

I grant that in the penultimate paragraph the authors did write, "Further investigation is needed to determine whether limiting contrast volume to less than the MCD during primary PCI improves patient outcomes. Future studies are also needed to evaluate the relative usefulness of contrast volume and renal function indices and contrast ratio for predicting CIN." The case remains open, as it should.

In many institutions, the cardiac catheterization laboratory has become a gold rush town, with about the same level of decorum. I have recently seen a colleague battered because he exceeded the "limit" of contrast proposed in the Marenzi article. If you could possibly keep this potential for carnage in mind as you vet these articles, I would be grateful.

Here is a Web-based calculator that I have created, based on the article: http://www.zunis.org/Risk_Calculators/Proposed% 20Contrast Limit in STEMI PCI.htm

References

1. Giancarlo Marenzi, Emilio Assanelli, Jeness Campodonico, Gianfranco Lauri, Ivana Marana, Monica De Metrio, Marco Moltrasio, Marco Grazi, Mara Rubino, Fabrizio Veglia, Franco Fabbiocchi, and Antonio L. Bartorelli Contrast Volume During Primary Percutaneous Coronary Intervention and Subsequent Contrast-Induced Nephropathy and Mortality Ann Intern Med 2009; 150: 170-177

Conflict of Interest:

None declared

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